Death Certificate - Ziliak, John_10/19/1977RECORD OF DEATH
� SOAT COUNTY DEPART�SEArT OF HE�
PRINCETON, INDIANA
THIS IS TO CERTIFY, that our records show � JOHN A. ZII,IAK
� 10�5/77 at 1AM 109 E. Gibson . Fiaubstadt, Ind. . t.
.-� month day yesr hour of death � .� street, hospital, ruisl
�
�-. Age at Death 72 Sex �a�-�-' Color �ite Marital Statuc Married .
-,: years � � write whether married or single
Primary cause of death given was PulmorL�ry emphysema -
Signed by � Harold' G: Petitjean, M'.D. � Haubstadt, Ind. �
�, physician or coroner � _ address . t
Place of burial or removal �ys: reter & Paul Haubstadt, Ind.
name of cemetery � address . —
Date of burial ' 10�7�%7 Wade Funeral Home Haubstadt, Ir�d.
� � " Funeral Dirnetor � � address
SEAL
. � � ., � � --
" � �� i.!;�� �� < !?.� �
Signea !/ ''. ,
Gibson County ilealth Commisaioner �
OaklandClty,-Ind. 10/12/�%
� � addresa . . ' � daLe
Recorded 1cea11y in book No. H-5� Page No. 3�' Filed: 10�11/77 : Zr.
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